A decade removed from the Clinton healthcare reform debacle, Democrats are once again on the forefront of the push for universal coverage for all Americans.
As the number of uninsured continues to climb-hitting 41.2 million in 2001, up 1.4 million from the previous year-Democrats are proposing an array of ideas to provide insurance to all Americans. How practical or far any of them will go is debatable, but that universal coverage is again on the radar of Democrats is an indication of how broken down they see the healthcare system, experts say.
To be sure, Democrats don't have sole ownership of the issue, and some experts say the Bush administration should be commended for putting forth proposals of their own to address the problem. But there is also a sense that healthcare is the domestic Achilles heel of the administration, making the uninsured and universal coverage a possible point of attack by Democrats.
"Polling data show this is one of the issues where people presume Democrats will do something more to their liking," says Ron Pollack, executive director of Families USA, a consumer advocacy group based in Washington.
Unlike a decade ago, Democrats are leaning away from a single-payer system with the government acting as the nation's insurer. Instead, many proposals treat employers as the gateway to health coverage.
The details are still works in progress, but the plans that have been revealed are wide-ranging and in some cases borrow from strategies of their GOP colleagues.
Some of the more prominent proposals being floated:
* A plan by Sen. John Breaux (D-La.) mandates that all Americans purchase health insurance. States would be required to set up insurance pools so residents could obtain the lowest group rates. Low-income families would have their premiums subsidized through refundable, advanceable tax credits, an idea borrowed from the Republican playbook.
* Sen. Edward Kennedy (D-Mass.) supports mandating employer coverage. Under his plan, employers would pay 75% of premium costs and employees would pay 25%. Low-income workers would receive financial assistance.
* Presidential candidate Rep. Richard Gephardt (D-Mo.) wants all employers to be required to cover their workers, with the government bearing most of the premium costs through refundable tax credits. He also advocates allowing Americans ages 55 and older to buy into Medicare and allowing working-poor parents to participate in the State Children's Health Insurance Program.
* Former Vermont Gov. Howard Dean, another Democrat running for president, is proposing to expand coverage by expanding Medicaid to everyone under age 23 and providing government subsidies to help everyone buy insurance.
The other Democratic candidates either have been silent on the subject or made references only in passing.
If there's one common point that these plans have, it's that the uninsured are in large part not the unemployed, but working people who cannot get insurance through their employers or on their own.
"They all recognize you have to do something strong in the workplace, then do something supplemental for low-income vulnerable populations," says Jack Meyer, president of the Economic and Social Research Institute, a Washington-based think tank.
Of the Democratic proposals, Breaux's idea has gotten the most attention, partly because of his stature as a leading centrist in his party.
"When he says we've got to get everyone covered, it has political consequences," Pollack says.
That puts Breaux in a position in which both Republicans and Democrats are willing to work on a bipartisan basis with him, says Mary Grealy, president of the Healthcare Leadership Council, a Washington-based coalition of healthcare executives.
"Breaux is one to watch because he has an ability to reach across the aisle," she says, adding that any plan that mandates employers to provide coverage will likely fail, a point Breaux also made recently.
"It didn't work before with Clinton," he says. As for his own plan, Breaux says that this year he is concentrating on rounding up support.
Although universal coverage is once again on Democrats' agendas, for most of the past decade it was a subject from which the party was happy to steer clear. Since Clinton's plan for universal healthcare tanked, there has been little willpower to rehabilitate the issue. The booming economy of the late 1990s pushed the uninsured off the political map while at the same time providers and the insurance industry remained vehemently against any idea of government interference in the insurance business.
Democrats historically have been strong advocates of the uninsured but pushing for universal coverage was seen as a political liability until recently. Today, though, a soft economy, a rising uninsured population and skyrocketing healthcare costs have made the environment ripe to revisit universal coverage.
Republicans, too, have pushed to expand health insurance coverage. Earlier this year, the Bush administration proposed reforming Medicaid by giving states greater flexibility to change their Medicaid programs without prior federal authority as is currently required. The plan, however, has drawn fire from critics who say it is a "block grant" approach that eventually could put states in a bind because there is no guarantee that they will receive additional federal funding to meet unexpected greater Medicaid demands.
The administration also has placed greater emphasis on community health centers to provide care for the poor, and is advocating refundable tax credits to help people purchase insurance. Although the GOP proposals would have less reach than the Democrats' plans, they also carry a lower price tag for the federal government, Meyer says.
Indeed, price could be a major obstacle to the proposals by Gephardt and Dean. According to one estimate, Gephardt's proposal could be as expensive as $2 trillion over 10 years, and Dean has said his plan will cost $600 billion over 10 years. Both say their plans will be partially financed by rolling back Bush's 2001 tax cuts.